Skin Deep - Clinical & Cosmetic Dermatology Blog

Skin Deep is a blog for dermatologists and skin care professionals with focus on theoretical, cosmetic and aesthetic dermatology. This blog is associated with ‘Dermatologists Sans Borders’ one of the largest curated groups of skin care professionals on facebook. If you are looking for non-technical information, please visit

Organizing Clinical Images in Dermatology

Do you find it difficult to keep track of your patient images when they come for follow up? Do you find it difficult to retrieve the right pictures for a conference presentation? Dermatology Image Tagger (DIT) is a free software to organize dermatology clinical pictures and to solve these problems.

DIT works by tagging images with patient ID, lesion, diagnosis, and date. You can search based on any of these tags! (Pictures of Mr. Smith, Pictures of psoriasis, etc.) The innovative feature is that the image file itself saves the tags but will not be visible on the display. So even if the image is copied to another computer, DIT will still be able to find it. [Download DIT FREE]

You can also share pictures with your friends, and they will be able to read these metadata using DIT. However, this introduces a security risk of inadvertently sharing this metadata on Facebook and other social media channels. To prevent the privacy risk, the tags are routinely encrypted with a password of your choice. If you share this password with your friends, they can view the tags.

I have hand coded it in Java and would be happy to hear feedback and feature requests. You can read about it and download it free from here: .[Just click the Facebook Like button to start download] This software made it into the ‘The Top 50 Tech Tools for Dermatology’ by DirectCapital. You can comment here for support tickets and feature requests!

See the instructions video below:

Labels: , ,

commentAdd Your Comments/Suggestions/Criticisms! | View Comments | Links to this post

Clinical Trial Assessment Scale for Cosmetic Dermatology

Clinical trials in cosmetic dermatology have some intrinsic limitations. Some of the prerequisites of an RCT such as blinding, allocation concealment and even randomization is difficult to achieve in cosmetic dermatology. Hence some of the well known scales for the methodological assessment of clinical trials such as Jadad and CONSORT have limited relevance in cosmetic clinical trial. Flawed evaluation of clinical trial quality allows flawed trials to thrive leading to clever new ways to distort trial results toward a favoured outcome.

Image Credit: By Evil Erin (

I have tried to enumerate well known biases in cosmetic dermatology and to put these ideas together as a framework for evaluating clinical trials in cosmetic dermatology. I have given it the acronym TASCDerm.

You can read more about TASCDerm and download a PDF score sheet from Dermatologists Sans Borders. [Click Here]


commentAdd Your Comments/Suggestions/Criticisms! | View Comments | Links to this post

Kudzu - Fair or not

Flowering kudzu is a fast-growing legume with ...
Flowering kudzu is a fast-growing legume with a grapelike odor. (Photo credit: Wikipedia)
First published in Dermatologists Sans Borders.

New herbal fairness agents are introduced every now and then though very few actually live up to the hype. However fairness industry is huge in most parts of Asia and research on new molecules always gets much attention. Most products of plant origin are introduced by cosmetic companies, and they often rely on old patents or anecdotal evidence of efficacy. Data on their effect on the melanin synthesis pathway is either not provided or deliberately hidden.

A new study (1) (open access. Link to the full paper below) demonstrates the effect of Kudzu, a group of plants in the genus Pueraria, in the pea family. It is well known that Kudzu is rich in isoflavones. The authors, using cell biology techniques, have demonstrated that the aerial part of P. thunbergiana can inhibit tyrosinase at the transcriptional level without cytotoxicity. In addition, it can also reduce tyrosinase maturation by inhibiting a-glucosidase.

Currently, numerous compounds are used for skin whitening, such as arbutin, hydroquinone, and kojic acid. Evidence suggests that the aerial part of P. thunbergiana, considered a weed in most parts of the world where it is seen, would one day be ranked higher in the list of depigmenting herbal products.

1. Han E, Chang B, Kim D, Cho H, Kim S. Melanogenesis inhibitory effect of aerial part of Pueraria thunbergiana in vitro and in vivo. Arch Dermatol Res. 2015 Jan;307(1):57-72. Epub 2014 Jul 26. PubMed PMID: 25063049; PubMed Central PMCID: PMC4282881.

Labels: , , , , ,

commentAdd Your Comments/Suggestions/Criticisms! | View Comments | Links to this post

Patient-reported outcome instruments for facial lines

The questionnaire we used to select patients.
The questionnaire we used to select patients. (Photo credit: Wikipedia)
It is often difficult to achieve an objective definition of beauty. It is even more difficult to assess the self-perception of beauty at a cognitive level. Though FDA often does not get involved much in the realm of cosmetic dermatology, Botox(R) is indeed a different matter as it is an injectable with real medical indications. Do upper facial lines (UFL) cause enough psychological morbidity to justify intervention? FDA might ask for real evidence and we better be ready.

To prove the impact of UFL treatment, first of all we need a validated tool. FDA recommends patient-reported outcome instruments or PRO as objective evidence. PRO as defined by FDA

is any report of the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else.

One of the PRO instruments available for upper facial lines is the FLO-11 questionnaire. But unfortunately FLO-11 is not validated to the FDA standards. You don’t usually find many good qualitative studies in cosmetic dermatology. But this study (1) stands apart and has been quite methodical in validating the FLO-11 questionnaire.

Yet another study in the same journal (2) presents another questionnaire called Aesthetic Dermatology and Emotional Well-being (DEBIE), designed to know the general population motivations with regard to skin appearance. Though DEBIE is quite long, the authors have done a good job in validating the questionnaire using qualitative research principles. An abridged version may be more practical.

Both these questionnaires will be useful for those planning patient satisfaction studies in cosmetic dermatology. All we need now is proof. Botulinum Toxin for UFL is fortunately our best shot at objective proof.

Read More

1. Yaworsky A, Daniels S, Tully S, Beddingfield F 3rd, Kowalski J, Fitzgerald K, Somogyi C, Burgess SM. The impact of upper facial lines and psychological impact of crow’s feet lines: content validation of the Facial Line Outcomes (FLO-11)
Questionnaire. J Cosmet Dermatol. 2014 Dec;13(4):297-306. doi: 10.1111/jocd.12117. PubMed PMID: 25399622.  ↩

2. Martínez-González MC, Martínez-González RA, Guerra-Tapia A. Aesthetic dermatology and emotional well-being questionnaire. J Cosmet Dermatol. 2014
Dec;13(4):336-45. doi: 10.1111/jocd.12109. PubMed PMID: 25399627. ↩

Labels: ,

commentAdd Your Comments/Suggestions/Criticisms! | View Comments | Links to this post

Dermatoscopy and The Ethics Report 2014

A recent study 1 from India has identified dermoscopic signs of evolving lesions of vitiligo. Authors observed reduced pigmentary network, absent pigmentary network, reversed pigmentary network, perifollicular hyperpigmentation and perilesional hyperpigmentation in the evolving vitigo lesions; a white glow was present in 27 (90%) of 30 patients. It is interesting to note that reversed pigmentary network, a well-known finding in dermatoscopy of melanoma and melanocytic nevus was also noted in many cases of evolving vitiligo. The authors conclude that dermoscopy scores over routine histopathology in the diagnosis of evolving lesions of vitiligo and can obviate the need for a skin biopsy in doubtful cases.

Image: Reversed Pigmentary Network in evolving lesions of vitiligo. (Image Credit Dr Sarvesh Thatte)

Skin Pathergy Test (SPT) – hypersensitivity of the skin to minimal trauma – is used as a diagnostic test in Behçet’s Disease with doubtful specificity. It is usually performed over the forearm with a blunt, sterilized needle. This article 2 recommends dermatoscopy for identifying sub-clinical pathergy reaction. The clinical relevance would have been much bigger if dermoscopy could replace biopsy in identifying pathergy. The authors have not clearly established the utility of dermoscopy in SPT. Authors have also mentioned about the significance of Thrombomodulin (TM) in pathergy. Thrombomodulin (TM) is a membrane-bound receptor of thrombin on vascular endothelial cells, which activates protein C and inactivates thrombin. High blood levels of TM were strongly correlated with positive skin pathergy test (SPT), suggesting that this test could be an alternative to the SPT.

  1. Thatte Sarvesh S, Khopkar Uday S. The utility of dermoscopy in the diagnosis of evolving lesions of vitiligo. Indian journal of dermatology, venereology and leprology 2014;80(6):505-508.
  2. Scherrer Maria A, Castro Lúcia P, Rocha Vanessa B, Pacheco Leonardo. The dermatoscopy in the skin pathergy testing: case series in patients with suspected behçet’s disease. Revista brasileira de reumatologia (english edition) 2014;54(6):494-498.
Medscape published the results of a survey conducted on over 21,000 global physicians, who answered the most wrenching ethical questions in medicine. Find out the changing opinions on controversial issues. Share your views on these issues with a comment below.

[Link to the report]

Labels: ,

commentAdd Your Comments/Suggestions/Criticisms! | View Comments | Links to this post

Role of Hyaluronic Acid Treatment in the Prevention Keloid Scarring

Hyaluronic acid as a volume enhancer is an important tool in any dermatologist’s armamentarium. This interesting in vitro study demonstrated that HA has the potential to normalize some of the characteristic features of keloid fibroblasts such as hyperproliferation activity, growth factor production, and extracellular matrix deposition depending on the specific genotype of the keloid fibroblast cell line. Administration of high molecular weight HA is able to reverse keloid deficiencies such as hyperproliferation and aberrant ECM deposition to a more normal phenotype. Though it is still early days as the lab results do not always translate to clinical improvement, we may soon be injecting hyalunoric acid fillers into keloids instead of steroids.

Labels: , ,

commentAdd Your Comments/Suggestions/Criticisms! | View Comments | Links to this post

How Chlorophyll Cuts Acne

Acne is a common teenage problem that leads to severe psychological morbidity. Isotretinoin is an effective treatment but has several serious side-effects making it a final resort in recalcitrant cases. Several anecdotal remedies exist with many websites claiming successful magic-bullets to lure gullible teenage girls to shell out their pocket money.
Image Credit Meghan @ Flikr (Image altered and text added)
Photodynamic Therapy (PDT) is another treatment modality that makes use of photosensitizers such as 5-Aminolevulinic acid (ALA) and Methyl Aminolevulinate (MAL). These chemicals get converted to porphyrin that can release reactive oxygen species on exposure to certain wavelengths of light. However, they can remain on the skin for a prolonged period leading to photosensitivity and is not suitable for dark skinned patients. The quest for a better photosensitizer has been a priority for quite some time.

A recent study published in JAAD* proposes Chlorophyll-a as the superior photosensitizer that we were waiting for. Chlorophyll-a is apparently much safer that ALA and MAL and has the following advantages:

Chlorophyll-a has intrinsic photosensitizer characteristics and does not need prior activation. Hence, the onset of action is fast.
Chlorophyll-a undergoes spontaneous permanent degradation with no risk of prolonged photosensitivity.
Chlorophyll-a is cheaper than ALA and MAL

Please share/like below to read the fourth advantage:

 The histological changes following PDT showed a sustained decrease in pilosebaceous units. Hence Chlorophyll-a PDT may be as sustainable as isotretinoin in preventing recurrence.  The combination of blue and red lights are used for activation. The study shows good promise for Chlorophyll-a PDT to emerge as a sustainable and effective treatment for recalcitrant acne.


*Byong Han Song, Dong Hun Lee, Byung Chul Kim, Sang Hyeon Ku, Eun Joo Park, In Ho Kwon, Kwang Ho Kim, Kwang Joong Kim, Photodynamic therapy using chlorophyll-a in the treatment of acne vulgaris: A randomized, single-blind, split-face study, Journal of the American Academy of Dermatology, Volume 71, Issue 4, October 2014, Pages 764-771, ISSN 0190-9622.
Keywords: acne vulgaris; chlorophyll-a; light-emitting diode; photodynamic therapy; photosensitizer; treatment

Labels: , , , ,

commentAdd Your Comments/Suggestions/Criticisms! | View Comments | Links to this post

About Me

As a Dermatologist and Informatician my research mainly involves application of bioinformatics techniques and tools in dermatological conditions. However my research interests are varied and I have publications in areas ranging from artificial intelligence, sequence analysis, systems biology, ontology development, microarray analysis, immunology, computational biology and clinical dermatology. I am also interested in eHealth, Health Informatics and Health Policy.


Bell Raj Eapen
Hamilton, ON